Provider Demographics
NPI:1760936942
Name:SMITH, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18603 BLACKMOOR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3719
Mailing Address - Country:US
Mailing Address - Phone:313-526-3269
Mailing Address - Fax:
Practice Address - Street 1:18603 BLACKMOOR ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3719
Practice Address - Country:US
Practice Address - Phone:313-526-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095653246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy